PROJECT SUMMARY AND ABSTRACT Opioid use disorders (OUDs) are epidemic and on the rise in the United States and have fueled significant increases in unintentional overdose. Rural areas in the US in particular have experienced significantly higher rates of overdose, both fatal and non-fatal, relative to urban areas. Overall, opioid addiction takes a tremendous toll on rural areas as they are often underserved with respect to healthcare and social services. Thus, there is an urgent need to address the ongoing crisis of opioid addiction in rural America. One avenue for addressing the crisis is to ensure sufficient access to evidence-based treatments for opioid use disorder (OUD). Medication-assisted treatment (MAT) with buprenorphine provides an effective outpatient option that can be implemented in a range of settings, including primary care. We propose to conduct a qualitative study as a first step of a developmental formative evaluation to examine the current status of buprenorphine prescribing practices and accessibility in two states with highly rural populations, Arkansas (where there are low numbers of buprenorphine waivered physicians per capita) and Kentucky (where there is a higher number of waivered physicians per capita). This work is a crucial first step in order to develop a larger subsequent study in which we will test implementation strategies to increase the adoption of buprenorphine treatment in both states. We propose two aims: 1) to conduct interviews among DATA-waivered physicians in rural areas of Arkansas and Kentucky across a range of practice settings in order to examine the range of influences upon the decision to obtain the waiver to prescribe buprenorphine as well as the barriers and facilitators to providing buprenorphine treatment; 2) to conduct interviews with non- waivered primary care providers in high-overdose, rural areas in both states to explore the perceived barriers and facilitators to providing buprenorphine treatment in rural primary care settings and the acceptability of existing treatment models for these settings. An important aspect of the proposed study is the inclusion of two states in different stages of the opioid epidemic: Arkansas, where the burden of opioid related morbidity and mortality is not yet severe, and Kentucky, where morbidity and mortality resultant from opioid use have reached unprecedented levels. The proposed study is an important first step in understanding the current landscape of buprenorphine treatment in rural states such as Arkansas and Kentucky and has significant implications for other rural states in the south seeking to expand access to buprenorphine treatment.